Too much medicine

Let’s start by literally thinking about ‘too much medicine’, by considering the problem of overprescribing. A recent review into overprescribing, suggested that we need culture change to reduce our reliance on medicines and to support shared decision making, in addition to systemic changes to improve patient records, transfers of care and clinical guidelines¹. So what does that mean in practice?

Tackling polypharmacy is complex. Through the following sections we’ll discuss adverse outcomes linked to too much medicine, appropriate versus problematic polypharmacy and barriers to de-prescribing. Using the case study of Brian, an elderly man with multimorbidity who complains he’s prescribed too many medications, we will consider the knowledge work of de-prescribing and how you can take a structured whole-person centred approach to reducing the risks associated with too much medicine.

However, we’ll first reflect on the reason why polypharmacy is such a headline topic!

Figure 1: Polypharmacy Headlines

In 2019-2020, approximately 1.1 billion prescription items were dispensed in English primary care. These prescriptions came at an enormous cost of 9.6 billion pounds!²

The number of prescriptions dispensed have doubled over the past 25 years. Although the rising trend appears to be levelling off, there is no sign of this coming down^{2, 3}.

There are many factors driving polypharmacy. Our ageing population is certainly contributing, with older age groups taking a larger number of medications.⁴ This ageing population is intricately linked with increasing multimorbidity. Evidence suggests that the more long-term conditions someone has, the more medicines they are prescribed.⁴

Guidelines often advocate starting, not stopping drugs, whilst the focus may be on single disease management rather than holistic care. Often the benefits of medications for an individual may be over-estimated, whilst the harms may not be fully appreciated.

When people are taking multiple medications, this can contribute to significant treatment burden, which impacts on medication adherence as well as the work of daily living (section 2.5). In fact, up to half of medicines prescribed for long-term conditions aren’t even taken!⁵ This could have huge implications on symptom control and hospital admissions. There is also the environmental impact and cost implication to consider of all these unused medications.

However, polypharmacy shouldn’t always be viewed negatively. Taking multiple different medications can come with risks, but may also offer significant health benefits. Clinical context is key, hence we will also consider this week when polypharmacy is appropriate.

So, what would an expert generalist do to help tackle the risks associated with polypharmacy?

We hope to provide some answers over the following sections. We’ll begin with a case study, that will perhaps remind you of someone you’ve recently encountered in your daily practice…

References

1. Department of Health and Social Care. National overprescribing review report. 2021. Available from: https://www.gov.uk/government/publications/national-overprescribing-review-report [Accessed 17/02/2022]
2. Department of Health and Social Care. DHSC Annual report and Accounts. 2021. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1052624/dhsc-annual-report-and-accounts-2020-2021-print-ready.pdf [Accessed 17/02/2022]
3. NHS Business Services Authority. Prescription Costs. Available from: https://www.nhsbsa.nhs.uk/prescribing-costs-2019 published#:~:text=Key%20findings%3A,in%202019%20was%201.12%20billion [Accessed 17/02/2022]
4. Payne RA, Avery AJ, Duerden M, Saunders CL, Simpson CR, Abel GA. Prevalence of polypharmacy in a Scottish primary care population. Eur J Clin Pharmacol. 2014; 70: 575-581. DOI: 10.1007/s00228-013-1639-9
5. Swinglehurst D, Fudge N. The polypharmacy challenge: time for a new script? BJGP. 2017; 67 (662): 388-389. DOI: 10.3399/bjgp17X692189